ATLAS

FOR THE INSERTION OF TRANSOSSEOUS WIRES AND HALF-PINS
ILIZAROV METHOD

M. A. CATAGNI

ATLAS
FOR THE INSERTION OF TRANSOSSEOUS WIRES AND HALF-PINS
ILIZAROV METHOD

EDITOR A. BIANCHI MAIOCCHI

AUTHOR
Maurizio A. Catagni, M.D., Orthopaedic Surgeon Professor at the Milano University, Medical School Founding Member and President of A.S.A.M.I. Italy Chief of the Orthopaedic Department and Ilizarov Unit “Alessandro Manzoni” Hospital - Lecco E-mail: maurizio@catagni.it http://www.asami.org/

EDITOR
Antonio Bianchi Maiocchi, M.D. Emeritus Head Department of Orthopaedics-Traumatology “Ospedale Maggiore” Novara, Italy Associate Professor Department of Orthopaedics University of Turin Founding Member of A.S.A.M.I. Italy

CONTRIBUTORS
John Joseph Maguire, M.D. North Queensland Orthopaedics, Townsville, Queensland, Australia Richard S. Page, BMedSci, MB, BS, FRACS (Orth) The Geelong Hospital, Geelong, Victoria, Australia Doron Sher, MBBS MBiomedE FRACS Vaucluse, Australia J. Pous i Barral M.D. Jefe de Servicio Mutua Universal – Barcelona (Author of the book: “Atlas anatomotopográfico de las extremidades y fijación externa anular”, Barcelona, 1988)

REVIEWERS
Dr. Kevin Coupe (USA) - Dr. Mark Dahl (USA) - Dr. Kevin Louie (USA) Dr. David Lowenberg (USA) - Dr. Kevin Pugh (USA) - Dr. Vladimir Schwartsman (USA)

Copyright 2003 Medi Surgical Video, Department of Medicalplastic srl, Via Mercadante, 15 - 20124 Milan - Italy ISBN N. 88-900250-2-6 First edition 2002 - Second revised edition 2003 Typesetting, lithos and printing: il quadratino, Milan, Italy Design: Antonella Corti, Architect, Politecnico of Milan, Italy Graphic Designer: Camillo Sassi General revision and proof reading: Marinella Combi
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. . . . . . and Kirienko A. . Makushin V.Radius and ulna right . . IV Foreword . . . . . Introduction . . . . . . . . . . . .D.Tibia and Fibula right . . . . . . Transfixion des membres Springer-Verlag. . . . . . . . . . . . . . . Milano. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Levels of the anatomical cuts of the lower extremity. . . . . . . . . . . . . . . . . . . . . . . . 1991 – Boileau Grant J. . . . . . nonunions. . . . . . . . . . . . . . . . . . Milano. . . . . . . . . . . . . .A. .M. . . . . . . Moskva. . . . . . . 1994 – Catagni M. . . .. . . . . . 1947 – Catagni M. Operating Room Guide to Cross Sectional Anatomy of the Extremities and Pelvis Raven Press. .Contents pag. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Springfield. . . . . . . . . . . . . .. . . . . . .. . . . Milano. .. . . . . 1987 – Green S. . . . . 45-46 . . . 1 . . . . . . . . . . . . . An Atlas of Anatomy Baillière. . . . . Akhondroplasija. . . . . .Pelvis left . . . . . . . . . . . . . . . . . . . . . . 3 . . . . . . . . . . . . . . . . . . . . . . Tindall & Cox. . . . . . .Femur right . . . . Berlin. . . . . Merloz Ph. . . . . . . . . . . . .M. 43 . . . . . . . . . . 41 . . . . . . . . . . . . . . . . . . . . . . . .Radius and ulna left . 1992 – Lehman W. . . . . . . . . . . . . . . . . . . . . 49 . . .A. . . . . . . . . . . . . . . . . . . . . . . . P. . . . . Transosseous Osteosynthesis Springer-Verlag. . . . . . . defekty dlinnykh kostej verkhnej konechnosti i kontraktury loktevogo sustava. . . . . . . IL. 23 . . . . . . . . . . . . . . . . . . . . . . . . . . Psevdoartrozy. . . . . . . . . . . . . . . . . . . . . . Shevtsov V. . . . . . . . . . . . . . . . . . . . .B. . . . . 1989 – Popkov A. . Bianchi Maiocchi and J. . . . . . . . Group: Editors A. . . . .. . . . . . . . . . . . . Complications of External Skeletal Fixation Charles C Thomas. . . . 2001 – Shevstov V. . . . . . . . . . . . . . . . .I. . . . . . . .. . . . . . .C. . .. . Berlin-Heidelberg-New York. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advances in Ilizarov Apparatus Assembly Medicalplastic. . . . . . . . . .I. . . . .Foot left . . . . . . . . . . . . .S.Foot left – Midfoot. . . . . 11 . . . . . . . . . . . . . . . Aronson Operative Principles of Ilizarov Medi Surgical Video. . . . 48 . . . . . . . . . . . . 1998 – Faure C. . .A. . . . . .Hand left – Metacarpal .Foot left – Hindfoot . . . . . . . . . . . . . . 33 Appendix . . . . . . . . . . . . . . . . . . . . . . . . 41 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tibia and Fibula left . . Kurgan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .A. . . . . . . . . . 2001 . . . . . . . . . . . New York. . . . . . . . . . . . . . . . 31 . . . . . . . . . . . . . . . . . . . .. . . Kuftyrev L. . . . . . .. . . . . . . . 21 . . . Malzev V. . . . . Soldatov Ju. 21 . . . . . .Humerus left. . . . . . . .Femur left . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V Basic principles of operative technique . . . . . . . 1981 – Ilizarov G. . . . . . . . Treatment of fractures.. . . . . VIII Levels of the anatomical cuts of the upper extremity . . . . . . . . . . . . . . . . .Foot left – clinical examples . . . . . . . . . . . . . . . . . .. . . . . . . . . .I. . . London. . . . . . . . . . . . . and Atar D. . . 47 . . . . . .. . . . . Forefoot . and bone loss of the tibia with the Ilizarov method Medicalplastic. . . . . . . . . . . . . . Paley D. . . . .V. . . . . . .Ankle Joint left . .A. . . . . . . . . . . . . . . . . 1 . . . . . . . . . . 50 References – A. . . . . . . . . .Humerus right . . . . . . . . . . .

etc are indicated. It is necessary to use them as follows: – wires ∅ 1. The surgeon can thus be more certain about the configuration of the underlying skeleton. The surgeons must always keep in mind that the anatomical segment may be pathological and therefore the anatomy can be abnormal. Other reference parts are those presented by palpation of the muscular interstices.8 mm and half pins ∅ 5 mm for humerus. The titanium pins are wicker and it is necessary to improve the diameter or the number of insertions. but the surgeon can use more suitable variants considering the location of the vessels and nerves. derived from a twenty-year experience. we have illustrated the present text using diagrams in which the names of vessels. It is necessary to carefully read the author’s Foreword which details the technique. We have divided both upper and lower limbs into 6 levels. . The references have been made according to the illustrated levels by means of direct palpation of the limb considering the osseous landmarks. The innovation of the hybrid “wires-half pins” assembly has decreased complications and has increased the tolerance of the apparatus for the patients. – wires ∅ 1. We have also introduced one standard cut of the pelvis and two cuts of the foot in order to reach a greater stability of the femur and tibia respectively. We indicate more usual sites of insertion (in our diagrams). In some anatomic positions (diaphysis of the tibia) the thread protrude through the skin. BIANCHI MAIOCCHI The use of transosseous wires and half pins for Ilizarov’s method necessitates intimate awareness of anatomic topography to avoid injury to nerves and vessels. A x-ray correspondance of the sections is useful for preassembly of the apparatus prior to operative application.8 mm and half pins ∅ 5 or 6 mm for the femur and tibia. nerves. The choice of the diameters depends especially on the weight of the patient and on the pathology to treat. the lateral epicondyle and the greater tuberosity for the humerus. The “Atlas” is an indispensable guide for all surgeons who begin to use this exacting technique. It is necessary to have no more than two threads protruding through the bone on the distal side of the half pin and no more than two threads on the near side. It is often necessary to have a greater stability at the level of the wrist in certain forearm pathological conditions. Correct pin insertion technique will reduce the risk of unnecessary tissue damage. For each of the transverse sections shown we have given its corresponding surface anatomical site that can be found by clinical examination.8 mm and half pins ∅ 4 or 5 mm for the forearm or in paediatric surgery. muscles. – wires ∅ 1. such as the lateral malleolus and the head of the fibula for the tibia.5 or 1. Note: the diameters of wires and half pins in the diagrams do not correspond to the reality. the radial styloid and head of radius for the forearm. We have added in metacarpal site two cuts (in the Appendix). After the world-wide diffusion of the hybrid wire – half pin methodology a great number of surgeons have requested a more updated Anatomical-Topographical Atlas with detailed anatomical cuts of the extremities.IV Introduction A. To better understand the technique of introduction of the wires and half pins it is advisable to consult the book “Advances in Ilizarov Apparatus Assembly”. On the basis of the above-mentioned request. but this has not any clinic importance as it does not affect the stability and does not produce infections.

This was achieved by adding an anterior half ring proximally which was connected to the original proximal ring. The changes have led to a decrease in pin tract infection rate from 20% to approximately 10% and significant improvements in patient comfort. When 2 wires are crossed at 90 degrees within the bone. The whole construct was more rigid and used a minimum of four wires per segment (2 wires per ring) rather than the 3 previously used. the tension diminishes.V Foreword Upgrade of the Ilizarov Method – wires and pins. In our subsequent courses and meetings. changes through the years M. Following an incident where it was necessary to remove the proximal femoral wires (during an acute rotational correction 2 wires compressed the sciatic nerve between them and needed to be removed) and replace them with a half pin construct. we decreased our complications and increased the chance of successful treatment. Degree of surgical difficulty also needs to be considered since some wires passed very close to neurovascular structures.Vaucluse . We attempted to modify the original femoral frame by moving the proximal arch distally. This causes problems with the wires due to deficiency of stability of the frame construct which in turn leads to soft tissue problems. The frames can be modified and stability increased by adding more wires but this needs to be done under anaesthesia. further limiting knee motion and producing quadriceps inhibition. In an attempt to avoid this problem and increase the stability of our frames we started using two levels of fixation per segment and abandoned the method of a third wire on a post (the ‘drop wire’). The problems noticed with the shoulder and proximal femur were similar. CATAGNI AND D. soft tissue problems and loss of joint range of motion. Although tension is maintained during distraction. In the proximal tibia.A. allowing greater knee flexion. SHER* After many years of using the original Ilizarov technique several problems were noticed. The patients complained that they were unable to lie supine and had great difficulty sleeping. we noticed that this patient had fewer problems sleeping and was generally more comfortable with his frame. This meant that the original complete ring was used slightly more distally. With other modifications of the frame that reduced or eliminated instability. but initial wire tension diminishes with time. to avoid this problem we changed from a single ring at the proximal tibia to a double ring construct. Their only alternative was to cut a hole in their bed but this was very expensive and still limited the positions they could adopt. These can be grouped into: patient pain or inconvenience. The healing rate *Doron Sher. fixation stiffness in all directions is equal to the stiffness that a single wire exhibits with respect to the force acting upon the wire perpendicular to its axis. These changes can be grouped both chronologically and by body region. This method was abandoned. Several modifications of the original Ilizarov technique have been utilised in what we now call the Ilizarov Method. The wire on the post was unstable because it could not be tensioned appropriately without deforming the ring and therefore less tension was applied to this wire. MBBS MBiomedE FRACS . This caused more osteolysis and a higher infection rate due to the increased movement of the wire which resulted.Australia . once the desired length is achieved and the frame locked for the consolidation phase. The original Ilizarov technique used multiple tensioned wires in order to reduce soft tissue trauma. In the hip this caused adduction and flexion contractures or subluxation of the femoral head since the patients were unable to sit and spent considerable periods of time lying in the lateral position with the affected side uppermost. we began teaching the method of fixation at two levels and emphasizing the importance of stable fixation. in case of lengthening. This began what was the first step in the evolution of the Ilizarov frame in the west. but by so doing we had to transfix a larger muscle mass.

The 2 oblique wires transfixed the quadriceps mechanism and created knee extension 2 contractures. The knee is put through a range of motion and the protruding ends of the wire observed. 3 wires were used to transfix the proximal tibia by Ilizarov. This is not the case with the half pins and so. The base of the triangle is created by a half ring and a stable construct is created. Insertion of the transverse distal femoral wire is a three stage process. This did not detract from the stability of the construct and significantly reduced patient pain. Since that time the half pin construct has been used on all proximal femora with excellent results (see ‘Delta’ configuration below). we will add a half pin rather than placing another wire close to the posterior neurovascular bundle. The quadriceps mechanism is avoided which allows knee movement. Slightly slower healing rates have been noted than were present with all wire constructs. Since there is less movement of the skin posteriorly then anteriorly these pins are well tolerated. caused few problems (this will be discussed further below). After about 3 weeks the wires then progressively loosen (particularly during consolidation). These are placed away from the achilles tendon and follow the longitudinal axis of the calcaneum as much as possible. The infections were always superficial and responded to oral antibiotics and wound care but were present in up to 20% of patients. The knee is then flexed to thirty degrees and the wire is passed back through the soft tissues on the medial side while maintaining the same bony alignment. the tensor fascia latae must be progressively divided until the wire no longer bends with knee movement. In 1986 it was noticed that one wire in particular caused considerable pain for the patient. although if extra stability is needed. The 2 oblique wires were replaced with 2 half pins into the subcutaneous border of the tibia (1 medial and 1 lateral). it is withdrawn below the soft tissues on the medial side but left in bone to maintain its general alignment. which again gives greater stability. Two cortex fixation is achieved and the patients have minimal discomfort from these pins. The two oblique wires originally used were replaced with one transverse wire and one half pin placed posteriorly in the sagittal plane. The wire that passed through the fibula head initially had few problems but after a few weeks osteolysis of the fibula head was noticed and then the skin infection rate in this region increased. This is not significant however and the increase in patient comfort far outways the slowing of the healing rate. If possible the wire should emerge posterior to the tensor fascia latae. The ‘delta’ configuration describes the ‘triangle’ shape created when 2 half pins are inserted into the proximal femur at an angle of approximately 60 degrees to each other (they are perpendicular to the bone) but in the same coronal plane. This reduced pin tract problems but the patients complained of heel pain where the pin entered the achilles tendon insertion. The 2 contructs have similar initial rigidity. The same technique is applied to the proximal humerus but fewer rings and pins can be used since the loads applied to this bone are significantly lower. If it bends on the lateral side only. As with other parts of the body Ilizarov originally used three wires in the distal femur. The anterior wires transfixed mobile skin and caused significant pain and the posterior wires were prone to contamination and subsequent infection. a high skin infection rate and significant knee stiffness from the patient’s unwillingness to flex their knee. This caused pain for the patient. long term. At least two linked half rings and at least 4 half pins are used. The pes and its’ overlying skin were irritated with any attempted knee movement. . If the wire does not bend with knee movement then its position is acceptable. The transverse wire. the wire is inserted through the distal femur (wires should be perpendicular to the surface of tubular bones where possible). The wires through the ankle have generally been well tolerated. The transverse wire caused little morbidity and was therefore not changed. In addition the patients are able to maintain knee movement because the quadriceps mechanism is not transfixed. This caused loss more than 60 degrees of knee motion which took several years to return to normal or near normal. The pins are placed in the same line as the wires were but in a posterior to anterior direction ( prior to half pin insertion it is important to blunt dissect the soft tissues in a longitudinal direction). This was subsequently modified to the current technique which is to use two oblique half pins and no wires. increased the knee range of motion and effectively halved the pin tract infection rate. When the surgeon is satisfied with the position of the wire. As the technique has evolved we have found it best to place the half pins as posterolateral as possible. If it bends on both the medial and lateral sides it must be withdrawn completely and replaced. As with other areas. The next modification made was to calcaneal fixation. The pin tract infection rates and hip pathology rates are significantly lower and the patients are more comfortable. With the knee in extension to judge the alignment of the leg. if inserted correctly.VI was acceptable and a new technique had been born. Following this the wire driver is changed to the medial side and the wire is withdrawn below the soft tissues on the lateral side. These 2 wires have been replaced by half pins. This wire passed from anterolateral to posteromedial and into the pes anserinus. The knee is flexed to approximately 90 degrees and the wire is passed through the soft tissues in a medial to lateral direction. the single transverse wire with 2 half pins is more rigid than the three wire construct. There has been little need to change these.

and congenital deformities. and decreased the frame’s ability to yield correction. I tend to simplify my frames. Another use for the olive wire is the closed reduction of fracture fragments. including malunion. . insufficient number of rings. The frame position can be corrected. We like to use the olives as a closed reduction device. For this reason Ilizarov devised the olive wire which improved initial fixation of the wire to the bone. When 2 oblique wires were used at this level at least one of these had to pass through a muscle belly. the corrective forces have to work against soft tissue fibrosis and muscle contracture. In many deformities. we were able to decrease the use of olive wires. we now realize that the initial problems with the use of the Ilizarov method were related to principal errors in surgical technique. The next technique change was at the mid tibial level. the pain and infection rates dropped and the ankle range of motion improved. This was also associated with infection and formation of a ring sequestrum. In this way it has greater resistance to the line of pull of the fibula. pain. The posteromedial wire passed very close to the ulnar nerve. and poor frame design. Frame rigidity is maintained and few skin problems are noticed. even very stable frames can encounter difficulties with correction. the circular frame is tolerated just as well as a monolateral frame. particulary anteromedially. Ideally they would be too big to cut through the bone but not big enough to cause extra soft tissue trauma. In regard to the application of the frame on the tibia. The tibia and fibula are thus transfixed in a one step process and the wire is then attached to the ring. All of these factors contributed to instability. A 3mm K wire is drilled percutaneously through the fibula and tibia in the original Ilizarov fashion. This requires frames of significant stability. Originally there were 2 wires at about 30 degrees to each other at the level of the epicondyles. When the reduction has been obtained and the frame applied. or pins with 1 wire (which passes obliquely but always exits anterior to the posteromedial border of tibia). inadequate levels of fixation. and it allows for easier correction of angular deformities. This avoids the ulnar nerve and is in an area which has relatively little skin movement. One passes from posterior to anterior through the distal triceps into the distal humerus just above the olecranon fossa and the second passes from posterolateral to anteromedial into the lateral epicondyle of the humerus. The most recent change has been to the method of tibiofibular fixation when lengthening the tibia. This caused pain and muscle scarring with a higher infection rate. In some cases. The solution was to pass a K wire using the old technique but use this as a guide to drill from anteromedially through the tibia and into the fibula. Following the change to anterior half pins at the proximal tibial level it was noticed that the patients lost knee range of motion due to the fibula being pulled distally (along with the lateral collateral ligament and associated structures). This was associated with a decrease in osteolysis and ring sequestrae. Using this technique there is no longer any loss of knee movement. When the oblique wire was replaced by half pins into the subcutaneous border of the tibia. and poor patient tolerance of the frame. Many surgeons mistakenly equate the Ilizarov method with the Ilizarov frame.VII The next modification was to the distal humerus. We did not wish to return to using the posterolateral wire since the complication rate without it was so much lower. The resistance of the osseous and non-osseous tissue can cause the wires to cut through the bone. The current technique is to pass a transvere wire at the level of the epicondyles in a medial to lateral direction. toward a monolateral frame while maintaining the mechanics of the circular fixator. There were problems with lack of stability due to the third wire and also soft tissue problems from skin movement. Unfortunately our experience showed that after 2 to 3 weeks in situ the olive wires caused osteolysis of the bone against which they were placed. It is important that the wire go from superior to inferior as well as from posterolateral to anteromedial. In retrospect. A half pin was then used which prevented the fibula migrating distally and could also be attached to the frame for additional fixation. stiff non- 2 union. we replace the olive wire with a standard smooth wire and half pin. We now use a more simple method which has achieved the same results. inappropriate wire tension. A third wire on a post passed transversely through the humerus more proximally with the ring place at the level of the crossed wires. After introduction of the half pins inserted perpendicular to the plane of correction. The Kwires can slide or even cut through the bone. This has the advantage of being a closed technique. These errors included the incorrect placement of the wires. In my personal practice. I see no advantage of a monolateral frame over the circular frame. We now use 2 half pins only. If it is applied correctly. They have 100x more resistance to fragment displacement than a wire alone. This lead to a loss of frame stability. but the bone does not follow the frame segment. While it worked well this method was very time consuming. especially in the humerus and femur. The fixation is augmented with two half pins. The wire driver is then moved to the anteromedial aspect of the tibia and the wire is withdrawn to be within the fibula. it is just as easy to care for post-operatively. I am able to apply a circular frame as quickly. osteoporosis. One can use the Ilizarov method even with a monolateral frame if he respects the biological parameters taught by Ilizarov. Beaded wires were disigned to prevent a bone fragment from sliding along a wire.

Drilling is then performed with the appropriate sized drill (4). Blunt dissection with a small clamp (i. (5) 5 . mosquito) is then used to separate the soft tissues down to bone (2). 4 Half pins or half wires are then inserted in similar fashion via a soft tissue-protecting sleeve. HALF PINS: a small skin incision is made with a scalpel at the appropriate position for pin insertion (1). vessels and tendons.e. can tension the tissues and further reduce the chance of inadvertent damage. during the insertion of half pins the following technique is recommended. Occasionally irrigate with cold saline solution to prevent heat build up. When drilling or inserting half pins the application of gentle pressure to the skin and soft tissues. 3 A tissue-protecting guide is then inserted along the tract and placed against the bone.VIII Basic principles of operative technique To prevent transfixing nerves. 1 2 The clamp is then opened to further separate the soft tissues (3). with the hand.

IX WIRES: During the insertion of wires at potentially dangerous sites. Green is recommended: “The Rancho Mounting Technique for Circular External Fixation”. Correct pin insertional technique will reduce the risk of unnecessary tissue damage. (8) Note: The surgeon must always keep in mind that the anatomical segment may be pathological and therefore the anatomy can be abnormal. 16 No. 1992 Vol. 6 Blunt dissection is then performed with the use of the clamp (mosquito) (7). reference to the original article of the author Stuart A. 8 RANCHO SYSTEM For details on the “Rancho System” technique.-Dic. 3. A skin incision is made at the appropriate point for insertion of the wire (6). The wire is then inserted in routine fashion. a similar technique may be used. 7 The wire is then introduced via the safe tract created by the clamp. Advances in Orthopaedic Surgery No. .

This traverses both the biceps and triceps M. Australia. is performed at the anterolateral site. When inserting the anterior half pin. At this application site. must be palpated and pushed laterally out of harm’s way. The first runs transversely and the second from antero lateral to postero medial. A second half pin can be placed from posterior to anterior. The crossing angle between these two wires should be between 20° and 30°. A fixation wire can be placed from anterolateral to posteromedial traversing both the biceps and triceps M. and this plane avoids the dorsal and ventral neurovascular structures. from posterolateral to anteromedial. During this insertion. Two wires may be inserted at this point. A fixation half pin is placed posteriorly. The first wire is inserted via the medial epicondyle. . posterior to the intertubercular groove. care must be taken to avoid the radial N.1 CHAPTER 1 Levels of the anatomical cuts of the upper extremity HUMERUS* right Greater Tuberosity 1 2 Placement of two half pins in the humeral head. Wire placement at this level is best achieved in the coronal plane. 3 4 CUT 1 CUT 2 5 CUT 3 6 CUT 4 CUT 5 CUT 6 Lateral Epicondyle * Contribution Dr John Joseph Maguire. Townsville. one or two pins may be used according to the needs of the individual case. A fixation wire can be placed in a medial-oblique direction from anterolateral to posteromedial. The reasons for this are that the bone is oriented in this axis. Extreme care must be taken with insertion of this wire. North Queensland Orthopaedics. A half pin is inserted anterior to the radial N from anterolateral to posteromedial. This wire traverse both the biceps and triceps M. The placement of half pins at the upper one third of the humeral diaphysis is carried out on the anterolateral side. behind the radial N from posterolateral to anteromedial at an angle of forty degrees to the sagittal plane. one or two half pins may be placed adjacent to the lateral epicondyle. A fixation wire can be placed in an oblique direction from anterolateral to posteromedial. This wire should exit as anterior as is possible on the lateral condyle. For additional fixation. Queensland. The second wire is inserted more anteriorly on the medial epicondyle and directed further posteriorly. the ulnar N. A fixation half pin is placed medial to the radial N from posterior to anterior.

LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY .HUMERUS 2 INSERTION WIRES AND HALF-PINS .RIGHT CUT 1 ANTERIOR CUT 4 ANTERIOR CUT 2 AXILLA ANTERIOR CUT 5 ANTERIOR CUT 3 ANTERIOR CUT 6 ANTERIOR .

A fixation wire can be placed in an oblique direction from anterolateral to posteromedial. The second wire is inserted more anteriorly on the medial epicondyle and directed further posteriorly. A fixation half pin is placed medial to the radial N from posterior to anterior.3 CHAPTER 1 Levels of the anatomical cuts of the upper extremity HUMERUS left Greater Tuberosity 1 2 Placement of two half pins in the humeral head. At this application site. A half pin is inserted anterior to the radial N from anterolateral to posteromedial. This traverses both the biceps and triceps M. from posterolateral to anteromedial 3 CUT 1 4 CUT 2 5 CUT 3 6 CUT 4 CUT 5 CUT 6 Lateral Epicondyle . posterior to the intertubercular groove. The placement of half pins at the upper one third of the humeral diaphysis is carried out on the anterolateral side. This wire traverse both the biceps and triceps M. Extreme care must be taken with insertion of this wire. The first wire is inserted via the medial epicondyle. one or two pins may be used according to the needs of the individual case. For additional fixation. care must be taken to avoid the radial N. A second half pin can be placed from posterior to anterior. The reasons for this are that the bone is oriented in this axis. behind the radial N from posterolateral to anteromedial at an angle of forty degrees to the sagittal plane. A fixation wire can be placed from anterolateral to posteromedial traversing both the biceps and triceps M. the ulnar N. During this insertion. is performed at the anterolateral site. This wire should exit as anterior as is possible on the lateral condyle. and this plane avoids the dorsal and ventral neurovascular structures. The crossing angle between these two wires should be between 20° and 30°. must be palpated and pushed laterally out of harm’s way. one or two half pins may be placed adjacent to the lateral epicondyle. Two wires may be inserted at this point. Wire placement at this level is best achieved in the coronal plane. A fixation half pin is placed posteriorly. The first runs transversely and the second from antero lateral to postero medial. When inserting the anterior half pin. A fixation wire can be placed in a medial-oblique direction from anterolateral to posteromedial.

LEFT ANTERIOR CUT 1 ANTERIOR CUT 4 AXILLA ANTERIOR CUT 2 ANTERIOR CUT 5 CUT 3 ANTERIOR ANTERIOR CUT 6 .LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY .HUMERUS 4 INSERTION WIRES AND HALF-PINS .

Posteriorly. underneath the cover of the deltoid. is performed at the anterolateral site. envelopes the portion of the humerus not covered with articular cartilage. teres minor and infraspinatus cover the humerus. The deltoid M. which transmits the long head of biceps. All of the critical neurovascular elements are now inferior and medial. posterior to the intertubercular groove.5 CHAPTER 1 HUMERUS left M. Note: be careful not to penetrate the articular surface. The humerus is 90% cancellous at this point and presents tuberosities anteriorly and laterally. Cephalic M. and the axillary N. lies the posterior humeral circumflex A. The postero medial half of this humeral section is covered by articular cartilage. The first runs transversely and the second from antero lateral to postero medial. On the lateral surface of the humerus. Deltoid T. Infraspinatus M. Subscapularis HEAD HUMERI Greater Tuberosity Glenoid SCAPULA M. Pectoralis Major ANTERIOR CUT 1 V. Deltoid This cross sectional cut is taken at the level of the lesser tuberosity. Biceps Brachii CORACOID PROCESS M. . Greater Tuberosity CUT 1 ANTERIOR Lateral Epicondyle Placement of two half pins in the humeral head. The tuberosities are separated anteriorly by a well-defined intertubercular groove.

Triceps Brachii (Long Head) This cross section is at the midpoint between the axillary fold and the head of the humerus. The humerus is beginning to expand into the proximal metaphysis and is covered laterally by the deltoid. accompanying the bundle. Radial N.HUMERUS 6 HUMERUS left PECTORAL REGION N. Ulnar N.V. It is a more commonly used site than the first cross section.V. Muscolocutaneous N. Brachial N. Greater Tuberosity AXILLA ANTERIOR CUT 2 Lateral Epicondyle The placement of half pins at the upper one third of the humeral diaphysis is carried out on the anterolateral side. The pectoralis major lies anteromedial and the long head of the triceps. care must be taken to avoid the radial N. Median A. Cephalic M. At this application site. Those not in this position include the posterior humeral circumflex A. posteriorly.LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY . . The majority of the neurovascular structures are located medial to the humerus. Biceps Brachii (Long Head) HUMERUS (Surgical Neck) M. When inserting the anterior half pin. Triceps Brachii (Lateral Head) M. Axillary A.V. and the axillary N. Posterior Humeral circumflex AXILLA ANTERIOR CUT 2 M. These structures are located posterior and lateral to the humerus. one or two pins may be used according to the needs of the individual case. Deltoid M. Biceps Brachii V.

Greater Tuberosity ANTERIOR CUT 3 Lateral Epicondyle A fixation wire can be placed from anterolateral to posteromedial traversing both the biceps and triceps M. A half pin is inserted anterior to the radial N from anterolateral to posteromedial. can be readily palpated medially. Brachial N. The brachial A. With the exception of the radial N. Musculocutaneous N. Triceps (Medial Head) A. Anteriorly in the deltopectoral groove lies the cephalic vein. all of the neurovascular elements are medial. is most anterior structure between the coracobrachialis and the biceps. The radial N. Ulnar N. The musculocutaneous N. is the most posterior structure as it sits on the medial head of the triceps. Biceps Brachii (Long Head) M. Brachialis M. Biceps Brachii (Short Head) N. Triceps (Long Head) M. The humerus is centralized within the extremity and surrounded by muscle. The ulnar N. Triceps Brachii (Lateral Head) This cross sectional cut is just distal to the axillary fold. is directly posterior. . Cephalic M.. Radial M. Median A. which may be visible. Profunda Brachii HUMERUS M.V.V.7 CHAPTER 1 HUMERUS left ANTERIOR CUT 3 V.

This traverses both the biceps and triceps M. Radial M. with the exceptions of the radial N. that is more anterior. . There is a moderate amount of dis- persion between them. Biceps Brachii (Long Head) N. A fixation half pin is placed medial to the radial N from posterior to anterior. Triceps Brachii (Medial Head) M. Brachial N. Greater Tuberosity ANTERIOR CUT 4 Lateral Epicondyle A fixation wire can be placed in an oblique direction from anterolateral to posteromedial. Triceps Brachii (Lateral Head) This cross section is at the level of the distal third of the humerus.LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY .. The neurovascular structures lie in the same position as in cut #3 i. Brachialis N. (medial).V. Median A.e. Triceps Brachii (Long Head) M. Coracobrachialis M. Biceps Brachii (Long Head) M.HUMERUS 8 HUMERUS left ANTERIOR CUT 4 V. which are more anterolateral and the musculocutaneous N. Cephalic N. Musculocutaneous M. Ulnar HUMERUS M.

.. the median N. Radial N. and the medial cutaneous N. Biceps Brachii A. Median V. Palpable structures include the biceps anteriorly and the triceps posteriorly. which is situated on top of the brachialis and underneath the brachioradialis. is located slightly more medial outside this sulcus. This sulcus contains the brachial A. these two muscles converge to form a deep sulcus. Greater Tuberosity ANTERIOR CUT 5 Lateral Epicondyle A fixation wire can be placed in a medial-oblique direction from anterolateral to posteromedial.9 CHAPTER 1 HUMERUS left M. Extreme care must be taken with insertion of this wire. Triceps Brachii (Long Head) M. Biceps) N. On the medial side. The humerus is triangular in shape and cortical through 50% of its diameter. behind the radial N from posterolateral to anteromedial at an angle of forty degrees to the sagittal plane. The ulnar N. A second half pin can be placed from posterior to anterior. V. Brachialis (M. Muscolocutaneus M. of the forearm. This wire traverse both the biceps and triceps M. Basilic ANTERIOR V. On the lateral side there is only the radial N.V. Brachioradialis HUMERUS This cross section is taken proximal to the elbow flexion crease. Triceps Brachii (Lateral Head) M. Ulnar M. Cephalic N. A fixation half pin is placed posteriorly. Triceps Brachii (Medial Head) M. Brachial N.

Pronator Teres M. Extensor Carpi Radial (Longus) Lateral Epicondyle HUMERUS M. Radial M. During this insertion. must be palpated and pushed laterally out of harm’s way.. anterior to the medial condyle of the humerus. transecting the distal humerus at the level of the medial epicondyle. Here. from posterolateral to anteromedial. Anconeus ULNA (Olecranon Process) This cross sectional cut is at the level of the flexion crease of the elbow. The radial and ulnar A. Flexor Carpi Radialis N. is the most critical structure to note at this level. Two wires may be inserted at this point. Extensor Carpi Radial Brevis M. The radial N. the humerus is cancellous in nature and flattened along its frontal border.HUMERUS 10 HUMERUS left ANTERIOR N. Ulnar M. The ulnar N. The second wire is inserted more anteriorly on the medial epicondyle and directed further posteriorly.V. For additional fixation. The crossing angle between these two wires should be between 20° and 30°. . Brachial T. This wire should exit as anterior as is possible on the lateral condyle. Brachioradialis M. Greater Tuberosity ANTERIOR CUT 6 Lateral Epicondyle Wire placement at this level is best achieved in the coronal plane. Flexor Carpi Ulnaris CUT 6 A.LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY . rests on top of the brachialis M. This runs with the median N. and this plane avoids the dorsal and ventral neurovascular structures. The reasons for this are that the bone is oriented in this axis. one or two half pins may be placed adjacent to the lateral epicondyle. the ulnar N. The first wire is inserted via the medial epicondyle. It has migrated dorsal to the axis of the humerus. and lies in the ulnar groove posterior to the medial epicondyle. Median M. have joined to form the brachial A. anterior to the lateral condyle. Biceps N. Brachialis M.

angulated 30° to the sagittal plane. Isolated radial fixation can be performed with a wire from anterior to posterior and a half pin from posterolateral to antero medial. and a half pin from posteromedial to anterolateral. perpendicular to the previous wire. A half pin can be inserted from a posterolateral position. using the open technique. Ulna fixation is performed with a wire from anteromedial to posterolateral angulated 40° to the coronal plane and a half pin from posteromedial to anterolateral. angulated 20° to the coronal plane. perpendicular to the first wire. angulated 15° to the sagittal plane. and a half pin from posterior to anterior. Isolated ulnar fixation can be done with a transverse wire (parallel to the coronal plane) and a half pin from posterior to anterior. Fixation of the ulna can be performed with a wire from anteromedial to posterolateral. angulated 10° to the sagittal plane. Fixation with half pins can be done posteriorly at an angle of 20° to the sagittal plane. posterior to the ulnar nerve. between the flexor carpi radialis and the median nerve. Ulnar fixation is performed with a wire directed from anteromedial to posterolateral angulated 45° to the sagittal plane and a half pin directed from posteromedial to anterolateral. Isolated radial fixation can be carried out with a wire directed from anterolateral to posteromedial. A half pin is inserted from posterolateral to anteromedial. Isolated ulnar fixation is much simpler and can be done with one transverse wire and a second wire from antero medial to postero lateral. Isolated radial fixation can be carried out with a wire directed from anterolateral to posteromedial. A half pin can be inserted from posterolateral to anteromedial at an angle approximating 20 degrees to the coronal plane. Fixation of the two bones is done with a wire from antero lateral to postero medial. perpendicular to the previous wire. The radius can be fixed with one wire directed from anterolateral to posteromedial angulated 45° with the coronal plane and a second wire inserted from anterior to posterior. 2 CUT 1 Head of Radius 3 CUT 2 CUT 3 CUT 4 CUT 5 CUT 6 4 5 Radial Styloid 6 .11 CHAPTER 2 Levels of the anatomical cuts of the upper extremity RADIUS AND ULNA right 1 Isolated fixation of the radius is difficult at this level because of the anterolateral vessels and the medial ulna. angulated 20° to the sagittal plane. angulated 20° to the coronal plane. perpendicular to the previous wire. Isolated radial fixation can be carried out with a wire directed from anterior to posterior. angulated 40° to the coronal plane. Fixation of the ulna can be performed with a wire from anteromedial to posterolateral. It can be done with a half pin inserted from postero medial to antero lateral. A half pin can be fixed in a posterolateral position.

LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY - RADIUS and ULNA

12

INSERTION WIRES AND HALF-PINS - RIGHT
CUT 1
ANTERIOR

CUT 4

ANTERIOR

ANTERIOR

CUT 2

CUT 5

ANTERIOR

ANTERIOR

CUT 3

CUT 6

ANTERIOR

13

CHAPTER 2

Levels of the anatomical cuts of the upper extremity RADIUS AND ULNA left
1
Isolated fixation of the radius is difficult at this level because of the anterolateral vessels and the medial ulna. It can be done with a half pin inserted from postero medial to antero lateral. Fixation of the two bones is done with a wire from antero lateral to postero medial. Isolated ulnar fixation is much simpler and can be done with one transverse wire and a second wire from antero medial to postero lateral, posterior to the ulnar nerve. Fixation with half pins can be done posteriorly at an angle of 20° to the sagittal plane. Isolated ulnar fixation can be done with a transverse wire (parallel to the coronal plane) and a half pin from posterior to anterior. Isolated radial fixation can be performed with a wire from anterior to posterior and a half pin from posterolateral to antero medial, angulated 20° to the sagittal plane. Isolated radial fixation can be carried out with a wire directed from anterior to posterior. A half pin can be inserted from posterolateral to anteromedial at an angle approximating 20 degrees to the coronal plane. Fixation of the ulna can be performed with a wire from anteromedial to posterolateral, angulated 20° to the coronal plane, and a half pin from posterior to anterior. Isolated radial fixation can be carried out with a wire directed from anterolateral to posteromedial, angulated 30° to the sagittal plane. A half pin can be fixed in a posterolateral position, perpendicular to the previous wire. Fixation of the ulna can be performed with a wire from anteromedial to posterolateral, angulated 20° to the coronal plane, and a half pin from posteromedial to anterolateral, angulated 10° to the sagittal plane. Isolated radial fixation can be carried out with a wire directed from anterolateral to posteromedial, angulated 40° to the coronal plane. A half pin can be inserted from a posterolateral position, perpendicular to the previous wire. Ulna fixation is performed with a wire from anteromedial to posterolateral angulated 40° to the coronal plane and a half pin from posteromedial to anterolateral, angulated 15° to the sagittal plane. Ulnar fixation is performed with a wire directed from anteromedial to posterolateral angulated 45° to the sagittal plane and a half pin directed from posteromedial to anterolateral, perpendicular to the previous wire. The radius can be fixed with one wire directed from anterolateral to posteromedial angulated 45° with the coronal plane and a second wire inserted from anterior to posterior, between the flexor carpi radialis and the median nerve, using the open technique. A half pin is inserted from posterolateral to anteromedial, perpendicular to the first wire.

2

Head of Radius

3 CUT 1

CUT 2 CUT 3 CUT 4 CUT 5 CUT 6

4

5

Radial Styloid

6

LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY - RADIUS and ULNA

14

INSERTION WIRES AND HALF-PINS - LEFT
ANTERIOR

CUT 1

ANTERIOR

CUT 4

ANTERIOR

CUT 2
ANTERIOR

CUT 5

ANTERIOR

CUT 3
ANTERIOR

CUT 6

the flexor digi- torum superficialis and the pronator teres. Head of Radius ANTERIOR CUT 1 Radial Styloid Isolated fixation of the radius is difficult at this level because of the anterolateral vessels and the medial ulna. Flexor Carpi Ulnaris N. runs medial to the ulna at the point of confluence of the flexor carpi ulnaris. Median Biceps Tendon N. Brachio Radialis M. Ulnar RADIUS M. has moved laterally and now runs along side the median N. The brachial A. Brachialis HUMERUS (TROCHLEA) M. Anconeus In this cross section the ulnar N. Fixation of the two bones is done with a wire from antero lateral to postero medial. Radial M. Fixation with half pins can be done posteriorly at an angle of 20° to the sagittal plane.15 CHAPTER 2 RADIUS and ULNA left ANTERIOR CUT 1 A. Pronator Teres M. . Brachial N. It can be done with a half pin inserted from postero medial to antero lateral. Isolated ulnar fixation is much simpler and can be done with one transverse wire and a second wire from antero medial to postero lateral.V. posterior to the ulnar nerve. Extensor Carpi Radialis (Longus and Brevis) Common Extensor Tendon ULNA M.

V.) M. Flexor Digitorum Profundus RADIUS M.LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY . Flexor Digitorum Sublimus N. Ulnar M. Pronator Teres M. and N. Brachii Radialis N.V. Radial (superficial) M. Supinator M. Median A. Isolated radial fixation can be performed with a wire from anterior to posterior and a half pin from posterolateral to antero medial. the superficial flexors and the deep flexors. The lateral cutaneous nerve of the forearm can be found in the subcutaneous plane along the anterolateral portion of the forearm. Ulnar N. Extensor Carpi Radialis N. Flexor Carpi Ulnaris This cross sectional cut is performed distal to the flexor crease of the elbow. Radial (prof. The median N. and is covered by the flexor digitorum sublimus and flexor pollicis longus. Flexor Carpi Radialis CUT 2 A. and superficial radial N. angulated 20° to the sagittal plane. . The radial A. are situated between the flexor carpi radialis and the brachioradialis. run together with the radial A. Extensor Digitorum Communis M. Here bony landmarks are restricted to the subcutaneous border of the ulna as the remainder of the forearm is covered with muscle. The posterior interosseous N. Radial M. is volar to the medial portion of the radius.RADIUS and ULNA 16 RADIUS and ULNA left ANTERIOR M. runs volar to the ulna at the point of confluence of the flexor carpi ulnaris.V. Extensor Carpi Radialis (Long) M. Head of Radius ANTERIOR CUT 2 Radial Styloid Isolated ulnar fixation can be done with a transverse wire (parallel to the coronal plane) and a half pin from posterior to anterior. The ulnar N. Extensor Carpi Ulnaris ULNA M.The ulnar neurovascular bundle is positioned directly volar to the ulna between the flexor carpi ulnaris and the flexor profundus.

Pronator Teres M. and radial A. Ulnar M.17 CHAPTER 2 RADIUS and ULNA left ANTERIOR M. The ulnar A. angulated 20° to the coronal plane. The superficial radial N. Extensor Carpi Radialis N.V.V. Radial (superf. Radial M. Extensor Com. Flexor Digitorum (superf. Flexor Digitorum (prof. Carpi Ulnaris M. remain covered by the flexor carpi ulnaris. Flexor Carpi Ulnaris RADIUS M. Flexor Carpi Radialis CUT 3 M. and a half pin from posterior to anterior.) A. is volar and central between the superficial and deep flexors of the fingers. The median N.V. Brachii Radialis A. The anterior interosseous artery has maintained its position on the volar surface of the interosseous membrane. M. Radial N.) In this cross section each of the three major neurovascular elements have assumed a deep position protected by the overlying muscles. Digiti Min. Flex. and N. Median M. Ulnar N. A half pin can be inserted from posterolateral to anteromedial at an angle approximating 20 degrees to the coronal plane.) M. Fixation of the ulna can be performed with a wire from anteromedial to posterolateral. Extensor Carpi Radialis N. . ANTERIOR Head of Radius CUT 3 Radial Styloid Isolated radial fixation can be carried out with a wire directed from anterior to posterior. are volar and lateral beneath the brachioradialis. Extensor Carpi Ulnaris ULNA M. Flex. Digitorum M.

Head of Radius ANTERIOR CUT 4 Radial Styloid Isolated radial fixation can be carried out with a wire directed from anterolateral to posteromedial.) M. Extensor Carpi Ulnaris ULNA This cross sectional cut is taken at the midpoint between the flexor creases of the elbow and wrist. Digitorum M. Extensor Carpis Brevis M. Median A. Flex. Pollicis Longus M. Ulnar M. angulated 20° to the coronal plane. Flexor Digitorum (prof. Flex. The two bones are maximally separated at this point. This level represents the apex of radial bowing. Extensor Carpi Radialis RADIUS M. and a half pin from posteromedial to anterolateral. Carpi M. A half pin can be fixed in a posterolateral position. and N. The ulnar A. The anterior interosseous artery has maintained its position on the volar surface of the interosseous membrane.LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY . angulated 30° to the sagittal plane. Digiti Min.V.RADIUS and ULNA 18 RADIUS and ULNA left M. The superficial radial N. Radial Sup. Flexor Digitorum (superf. remain under the cover of the flexor carpi ulnaris. Extensor Long. The median N. and radial A. Fixation of the ulna can be performed with a wire from anteromedial to posterolateral.) N. Extensor Comm. are volar and lateral underneath the brachioradialis. Flexor Carpi Radialis CUT 4 ANTERIOR A. Extensor Indicis M. perpendicular to the previous wire.V. angulated 10° to the sagittal plane.V. Radial N. M. . Flexor Carpi Ulnaris M. Ulnar N. is volar and central between the superficial and deep flexors of the fingers. M. The three major neurovascular elements have assumed a deep position protected by overlying muscles.

M. The ulnar A.V. Ulna fixation is performed with a wire from anteromedial to posterolateral angulated 40° to the coronal plane and a half pin from posteromedial to anterolateral. Flexor Carpi Ulnaris M. is on the medial side of the radial wrist flexor.19 CHAPTER 2 RADIUS and ULNA left N.V. lies superficially and can be found slightly lateral to the flexor carpi radialis. The terminal branches of the anterior interosseous N. lies subcutaneously over the abductor pollicis longus. Flexor Digitorum profundus RADIUS M. Ulnar M. Radial N. The radial A. angulated 40° to the coronal plane. Extensor Digiti Minimi ULNA In this cross sectional cut the superficial radial N.V. are volar and medial under the increasing mass of the flexor carpi ulnaris. Median CUT 5 ANTERIOR A. Flexor Carpi Radialis M. A half pin can be inserted from a posterolateral position. angulated 15° to the sagittal plane. . Extensor Carpi Radialis Longus and Brevis M. Radial sup. Flexor Digitorum sublimus M. Extensor Indici M. are deeply located on the ulnar border of the radius. The median N. Abductor Pollicis M. Head of Radius ANTERIOR CUT 5 Radial Styloid Isolated radial fixation can be carried out with a wire directed from anterolateral to posteromedial. Digitorum M. and N. Pronator Quadratus A. Ulnar N. Extensor Comm. between it and the flexor digitorum sublimus. Extensor Carpi Brevis M. perpendicular to the previous wire.

. Flexor Carpi Ulnaris N. being situated between the flexor digitorum superficialis and the flexor carpi radialis. A half pin is inserted from posterolateral to anteromedial.V. The radius can be fixed with one wire directed from anterolateral to posteromedial angulated 45° with the coronal plane and a second wire inserted from anterior to posterior. Ulnar M. using the open technique. As in 30% of the normal population.LEVELS OF THE ANATOMICAL CUTS OF THE UPPER EXTREMITY . Radial Sup.RADIUS and ULNA 20 RADIUS and ULNA left ANTERIOR M. Head of Radius ANTERIOR Radial Styloid CUT 6 Ulnar fixation is performed with a wire directed from anteromedial to posterolateral angulated 45° to the sagittal plane and a half pin directed from posteromedial to anterolateral. is found between the flexor carpi radialis and the abductor pollicis longus. Extensor Indicis ULNA M. perpendicular to the previous wire. Pronator Quadratus M.V. Extensor Digitorum Communis In this cross sectional cut most of the arteries and tendons can be accurately localized by palpation as they lie superficially. lie volar and medial and are protected by the flexor carpi ulnaris T. Flexor Pollicis Longus M. Flexor Digitorum Profundus A. Flexor Digitorum Superficialis CUT 6 N. Extensor Digiti Minimi M. Pronator Quadratus RADIUS N. The ulnar A. perpendicular to the first wire. Longus Extensor Carpi M. is slightly more radial in position. M. this diagram shows no palmaris longus T.V. Median A. The median N. between the flexor carpi radialis and the median nerve. Extensor Carpi Radialis Longus and Brevis M. Ulnar M. Radial M. The radial A.

patients treated with bone transport and lengthening are at risk of injury to the profunda or femoral A. The anterior and lateral quadrants are the safest for pin insertion at this level. the latter being tolerated. one through the lateral intermuscular septum. The medial and lateral surfaces of the femur can also be utilised for fixation by means of two half pins inserted in a posteromedial and a posterolateral position respectively. There is a risk of late haemorrhage or pseudoaneurysm formation.The Geelong Hospital Geelong. to allow for knee motion. over time. Again additional release of the soft tissues. In particular. wires are poorly tolerated at this level. This is again placed to avoid the medial neurovascular structures. An additional fine wire can be placed obliquely in the anterolateral to slightly posteromedial direction. The half pin is placed in a more posterolateral position. However. This is necessary to find the isometric point within the iliotibial band and fascia lata. FRACS (Orth) . then it is backed off and reinserted. The insertion of half pins at this level is from lateral to anteromedial. The insertion of half pins at this level is from posterolateral to anteromedial. CUT 1 CUT 2 4 CUT 3 CUT 4 5 CUT 5 6 CUT 6 Lateral Epicondyle * Chapter contributed by: Dr. may be necessary to allow adequate knee motion. therefore the half pin is preferred in this situation. with a higher risk of soft tissue damage. avoiding the lateral cutaneous N of thigh. At the time of insertion the muscle fibres need to be opened with an artery type forceps in line with their fibres. . The placement of the half pin and oblique posterolateral to anteromedial wire is the same as for cut four.21 CHAPTER 3 Levels of the anatomical cuts of the lower extremity FEMUR* right Greater Trochanter 1 2 3 At this level the recommended fixation is performed using one half pin (6mm) inserted from anterolateral to posteromedial. evident with movement in the wire. Page. A distal reference wire is usually the first one inserted in femoral fixation using a fine wire fixator. transfixing the vastus intermedius and the rectus femoris. the first from posterolateral to anteromedial. Australia. Alternatively two wires can be inserted. BS. One optional transosseous wire can be inserted in an oblique anteromedial to posterolateral direction and a second from postero lateral to anteromedial.Orthopaedic Surgeon . If the soft tissues are seen to impinge. in particular the iliotibial band. posterior to the vastus lateralis. BMedSci. Victoria. MB. If the skin alone is tenting then the wire is passed through to the opposite side and then driven back through the skin while the knee is in a different position of flexion. This is a transcondylar wire inserted in the transverse line at the level of the superior pole of the patella. through the vastus lateralis. exiting along the anterior portion of sartorius. directed more anteriorly and along the line of the anterior aspect of the lateral intermuscular septum. Great care must be taken to ensure the wire does not impinge on the soft tissues and limit knee motion. and a second one from posterolateral to anteromedial: the two pins are angulated from 30-40°. Richard S. The second wire is placed in a similar plane to the half pin. This means the wire is inserted so that there is no movement in the wire as the knee is examined through a 0° to 90° range of motion.

RIGHT CUT 1 ANTERIOR CUT 4 ANTERIOR ANTERIOR CUT 2 ANTERIOR CUT 5 ANTERIOR CUT 3 ANTERIOR CUT 6 .FEMUR 22 INSERTION WIRES AND HALF-PINS .LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY .

therefore the half pin is preferred in this situation. This is a transcondylar wire inserted in the transverse line at the level of the superior pole of the patella. over time. The insertion of half pins at this level is from lateral to anteromedial. one through the lateral intermuscular septum. The insertion of half pins at this level is from posterolateral to anteromedial. CUT 1 CUT 2 4 CUT 3 CUT 4 5 CUT 5 6 CUT 6 Lateral Epicondyle . the latter being tolerated. If the soft tissues are seen to impinge. directed more anteriorly and along the line of the anterior aspect of the lateral intermuscular septum. The medial and lateral surfaces of the femur can also be utilised for fixation by means of two half pins inserted in a posteromedial and a posterolateral position respectively. However. Great care must be taken to ensure the wire does not impinge on the soft tissues and limit knee motion. At the time of insertion the muscle fibres need to be opened with an artery type forceps in line with their fibres. to allow for knee motion. This is necessary to find the isometric point within the iliotibial band and fascia lata. This means the wire is inserted so that there is no movement in the wire as the knee is examined through a 0° to 90° range of motion. posterior to the vastus lateralis. In particular. Alternatively two wires can be inserted. then it is backed off and reinserted. The anterior and lateral quadrants are the safest for pin insertion at this level. in particular the iliotibial band. exiting along the anterior portion of sartorius. One optional transosseous wire can be inserted in an oblique anteromedial to posterolateral direction and a second from postero lateral to anteromedial. through the vastus lateralis. patients treated with bone transport and lengthening are at risk of injury to the profunda or femoral A. may be necessary to allow adequate knee motion. If the skin alone is tenting then the wire is passed through to the opposite side and then driven back through the skin while the knee is in a different position of flexion. This is again placed to avoid the medial neurovascular structures. avoiding the lateral cutaneous N of thigh. Again additional release of the soft tissues. the first from posterolateral to anteromedial. There is a risk of late haemorrhage or pseudoaneurysm formation. An additional fine wire can be placed obliquely in the anterolateral to slightly posteromedial direction. transfixing the vastus intermedius and the rectus femoris. The placement of the half pin and oblique posterolateral to anteromedial wire is the same as for cut four. A distal reference wire is usually the first one inserted in femoral fixation using a fine wire fixator. The half pin is placed in a more posterolateral position. The second wire is placed in a similar plane to the half pin. wires are poorly tolerated at this level. and a second one from posterolateral to anteromedial: the two pins are angulated from 30-40°. evident with movement in the wire. with a higher risk of soft tissue damage.23 CHAPTER 3 Levels of the anatomical cuts of the lower extremity FEMUR left Greater Trochanter 1 2 3 At this level the recommended fixation is performed using one half pin (6mm) inserted from anterolateral to posteromedial.

LEFT ANTERIOR CUT 1 ANTERIOR CUT 4 ANTERIOR CUT 2 ANTERIOR CUT 5 ANTERIOR ANTERIOR CUT 3 CUT 6 .FEMUR 24 INSERTION WIRES AND HALF-PINS .LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY .

. with the medial apex corresponding to the lesser trochanter. runs down in a line midway between the ischium and the femur. Sciatic ISCHIAL TUBEROSITY M. Sartorius A. Vastus int. Gluteus Maximus This transverse section is at the level of the intertrochanteric line. CUT 1 ANTERIOR Lateral Epicondyle At this level the recommended fixation is performed using one half pin (6mm) inserted from anterolateral to posteromedial. Obturator Internus FEMUR (Neck) FEMUR (Greater Trochanter) M. At this level the femur is triangular in cross section. The ischium is palpable posteromedial and represents an important landmark for the sciatic N.V. PUBIS M. to its medial side. Femoral M. Posteriorly. Pectineus ANTERIOR CUT 1 M. over the obturator internus. M. the sciatic N. The femoral A. Other arteries that may be encountered at this level include the ascending branch of the lateral circumflex femoral A. At this level. Obturator Externus M. Quadratus Femoris N. on its lateral aspect and the femoral V. gameli. Vastus lat. M. Rectus Femuris M. and the medial circumflex A.N. is palpable Greater Trochanter anteromedial where it runs with the femoral N. and a second one from posterolateral to anteromedial: the two pins are angulated from 30-40°. fibres of the gluteus cover the nerve posteriorly. where the femur is relatively superficial. Tensor fascie M.25 CHAPTER 3 FEMUR left M. and quadratus femoris. Iliopsoas later.

with its variable perforating branches. A. Adductor Longus M. and the inguinal ligament superiorly. are rapidly diverging in order to innervate the extensor musculature.V. Vastus lat. and distal to the intertrochanteric line. in addition to the femoral A and V. posterior to the vastus lateralis. Femoral Prof.V.FEMUR 26 FEMUR left ANTERIOR M. Semimembranosus M. Biceps Femoris M. This section is taken at the level of the gluteal fold. The sciatic N. Gluteus Maximus N. Adductor Brevis M. is posterior and medial in respect to the femur.LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY . lying on the upper portion of adductor magnus. Sciatic M. Sartorius CUT 2 M. Semitendinosus M. Anteriorly. In the middle of the cross section at this level lies the profunda femoris A. The femur is located in the anterolateral quadrant of the transverse section. Pectineus FEMUR M. These structures are located anterior and medial within the femoral triangle formed by the sartorius and Greater Trochanter pectineus. A. The femoral pulse assists in the localization of the femoral N. the fascicles of the femoral N. Adductor Magnus M. Rectus Femoris M. The adductor muscle group is more medial. ANTERIOR CUT 2 Lateral Epicondyle The insertion of half pins at this level is from lateral to anteromedial. avoiding the lateral cutaneous N of thigh. It is contained between the gluteus maximus and the semimembranosus. Vastus int. Gracilis M. Adductor Brevis M.N. Femoral M. .

patients treated with bone transport and lengthening are at risk of injury to the profunda or femoral A. with a thicker cortex. Alternatively two wires can be inserted. Biceps Femoris N. are more medial to the femur entering the sub-sartorial canal. is a significant structure at this level and it lies between the femoral A. ANTERIOR CUT 3 Lateral Epicondyle The insertion of half pins at this level is from posterolateral to anteromedial. Vastus lat. A. over time.27 CHAPTER 3 FEMUR left ANTERIOR M. The femoral A. M. wires are poorly tolerated at this level. through the vastus lateralis. Note: in the femoral diaphysis the half pin is better tolerated. and distal to the intertrochanteric line. Semitendinosus CUT 3 M. At the time of insertion the muscle fibres need to be opened with an artery type forceps in line with their fibres. the first from posterolateral to anteromedial.V. FEMUR M. Greater Trochanter along with the femoral N.V. Rectus Femoris M. The femur is still anterolateral in position. one through the lateral intermuscular septum. and V. surrounded by quadriceps. therefore the half pin is preferred in this situation. Adductor Longus M.. with a higher risk of soft tissue damage. Semimembranosus M. . Vastus med. posterior to the vastus medias. to allow for knee motion. Sciatic M. M. This section is distal to the gluteal fold. Sartorius A. transfixing the vastus intermedius and the rectus femoris. The profunda femoris A. Femoral V. Vastus int. Long Gr. It is becoming more circular in cross section. However. Adductor Magnus M. Saphenous M. Femoral prof. Adductor Brevis M. The wires are used only in special cases. Gracilis M.N. and the femur. In particular. The second wire is placed in a similar plane to the half pin. There is a risk of late haemorrhage or pseudoaneurysm formation. Biceps Long.

in the medial zone. which may be dividing into the tibial N. directed more anteriorly and along the line of the anterior aspect of the lateral intermuscular septum. Semimembranosus M. and located in the anterolateral quadrant. Sartorius M. Note: in the femoral diaphysis the half pin is better tolerated. The wires are used only in special cases. still undercover of sartorius withGreater Trochanter in the adductor canal. Adductor Longus M. Prof. the femur and the sciatic N.. Rectus Femoris M. ANTERIOR CUT 4 Lateral Epicondyle The anterior and lateral quadrants are the safest for pin insertion at this level. Biceps Femoris (Long head) M. vastus medialis to the lateral side and the adductor magnus posteriorly. lie directly posterior to the femur covered by the biceps. along with what is now becoming the saphenous N. . The femur still is circular with thick cortices. Vastus med. is again significant at this level and lies between the femoral A. the latter being tolerated. and accompanying perforating branches of the profunda femoris A. Gracilis M. have come to lie directly medial to the femur.FEMUR 28 FEMUR left ANTERIOR CUT 4 M. Femoral V. with vastus lateralis anterolateral and semimembranosus medially. One optional transosseous wire can be inserted in an oblique anteromedial to posterolateral direction and a second from postero lateral to anteromedial. Semitendinosus This level is distal to the gluteal fold and the subtrochanteric line. Saphenous M. Adductor Magnus FEMUR M.V. Vastus intermedius A. The femoral A and V.LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY . Vastus lateralis M. and the common peroneal N. Femoral M. The sciatic N. Biceps Femoris N. Here it is almost surrounded by the quadriceps musculature. The canal is bound by the sartorius anteriorly. The half pin is placed in a more posterolateral position. The profunda femoris A. Sciatic M. A.V..

Femoral M. and V. This is again placed to avoid the medial neurovascular structures. and posterolateral to this is the sciatic N as it begins to branch into the tibial N. Vastus Lateralis A. Posteriorly the linea aspera gives attachment to the intermuscular septi. Semimembranous Magnus M. and the common peroneal N. ANTERIOR CUT 5 Lateral Epicondyle The placement of the half pin and oblique posterolateral to anteromedial wire is the same as for cut four. Semitendinosus M. lie beneath in the posteromedial zone. adjacent to the vastus medialis is the femoral A. Vastus medialis M. The wires are used only in special cases. Because of these structures such zone must be avoided. Gracilis M.29 CHAPTER 3 FEMUR left ANTERIOR CUT 5 M. . Greater Trochanter The areas to avoid at this level are on either side of adductor magnus. Saphenous M. Biceps Femoris (Long head) The femur remains primarily circular and cortical in nature. Tibial and Common Peroneal M. Vastus intermedius FEMUR M. exiting along the anterior portion of sartorius. In muscular individuals identification of the sartorius can be very helpful as the femoral A.V. and V. Adductor Magnus V. Sartorius M. as they pass to the posterior aspect of the femur. Medially. Note: in the femoral diaphysis the half pin is better tolerated. An additional fine wire can be placed obliquely in the anterolateral to slightly posteromedial direction. Rectus Femoris M. Biceps Femoris (Short head) N.

evident with movement in the wire. This means the wire is inserted so that there is no movement in the wire as the knee is examined through a 0° to 90° range of motion. M. . lies behind the biceps femoris tendon and the saphenous V. If the soft tissues are seen to impinge. The medial and lateral surfaces of the femur can also be utilised for fixation by means of two half pins inserted in a posteromedial and a posterolateral position respectively.LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY . ANTERIOR CUT 6 Lateral Epicondyle A distal reference wire is usually the first one inserted in femoral fixation using a fine wire fixator. Popliteal M. Popliteal This section is taken about 4 cm proximal to the knee joint. Note: avoid placement of the wires or half pins distal to superior pole of the patella to prevent penetration of joint capsule which can lead to a septic joint. At this level the femur is trapezoidal in cross section and is almost entirely cancellous. In addition the common peroneal N. at the level of the superior pole of the patella. The medial and lateral extensor retinacula extend from either surface of the patella. runs along the sartorius muscle. The major neurovascular structures are located along the posteromedial surface of the lateral femoral condyle.FEMUR 30 FEMUR left ANTERIOR CUT 6 T. This is necessary to find the isometric point within the iliotibial band and fascia lata. and posteriorly for the tibiofemoral articulation. in particular the iliotibial band. Quadriceps Tendon Quadriceps bursa FEMUR M. Gracilis M. is Greater Trochanter usually palpable posteriorly which aids in the artery’s localization. Semitendinosus A. Again additional release of the soft tissues. then it is backed off and reinserted. Semimembranous M. This is a transcondylar wire inserted in the transverse line at the level of the superior pole of the patella. Adductor Magnus M. Vastus lat. Great care must be taken to ensure the wire does not impinge on the soft tissues and limit knee motion. M. If the skin alone is tenting then the wire is passed through to the opposite side and then driven back through the skin while the knee is in a different position of flexion. Biceps Femoris N. Saphenous M. Common Peroneal N. Vastus med. The articular cartilage of the knee joint is present anteriorly for the patellofemoral joint. Sartorius V. may be necessary to allow adequate knee motion.V. The popliteal A.

Head of fibula CUT 1 2 3 CUT 2 4 5 CUT 3 6 CUT 4 CUT 5 CUT 6 Lateral Malleolus . The forceps is used to displace the soft tissues and therefore protect the anterior neurovascular bundle. for example in tibial lengthening. allowing safe pre-drilling and insertion of a 5 or 6mm half pin. Alternatively a stabilizing half pin can be inserted anteriorly. Tibial fixation is with a medial-oblique wire and a half pin inserted into the medial aspect of the tibia perpendicular to the medial aspect. A reference wire is usually first inserted for fine wire fixation. and pulled through to be flush with bone. The fibular stabilization takes place through a lateral oblique wire directed from posterolateral to anteromedial. A distal tibial reference wire is the initial fixation used. while the knee is flexed and the pin is driven through the fibular head. The fine wire is inserted slightly obliquely to the transverse plane of the tibia to engage it in its widest portion. The medial one can be used to also fix the fibula head. medially and slightly distally toward the closest available ring. This should be done with care using a limited open technique through a small incision. The wire at this level is placed almost parallel to the frontal plane of the tibia. Additional stabilisation can be achieved with a wire directed form antero lateral to posteromedial. This is inserted in the transcondylar transverse plane anterior to the fibula. The wire is cut off flush with skin. if this is the case a drill guide and trochar should be used.31 CHAPTER 4 Levels of the anatomical cuts of the lower extremity TIBIA and FIBULA right 1 The diagram demonstrates the wide medial and lateral access to the tibia that is available for pin insertion. which is dilated with an artery forceps. Alternatively a 2-3mm smooth pin can be used to transfix the proximal tibio-fibular joint. The half pin is inserted again on the medial aspect. The insertion of the wire and half pin at this level is similar to that described for Cut Two and Three. with a direct medial to lateral wire. slightly obliquely to the wire as shown in the diagram. This is inserted by palpating and protecting the common peroneal N. The half pin is inserted perpendicular to the subcutaneous border of the tibia on the medial aspect. with the thumb and holding the soft tissues posteriorly. Optimum fixation is then obtained using two half pins placed anteriorly. The pin is directed anteriorly. lateral to the tibialis anterior tendon. anterior to the neurovascular bundle.

RIGHT 2 3 ANTERIOR CUT 1 4 1 CUT 4 ANTERIOR CUT 2 ANTERIOR CUT 5 ANTERIOR ANTERIOR CUT 3 CUT 6 ANTERIOR .LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY .TIBIA and FIBULA 32 INSERTION WIRES AND HALF-PINS .

This should be done with care using a limited open technique through a small incision. Additional stabilisation can be achieved with a wire directed form antero lateral to posteromedial. The wire is cut off flush with skin. lateral to the tibialis anterior tendon. Optimum fixation is then obtained using two half pins placed anteriorly. This is inserted in the transcondylar transverse plane anterior to the fibula. The forceps is used to displace the soft tissues and therefore protect the anterior neurovascular bundle. and pulled through to be flush with bone. Alternatively a 2-3mm smooth pin can be used to transfix the proximal tibio-fibular joint. anterior to the neurovascular bundle. The fibular stabilization takes place through a lateral oblique wire directed from posterolateral to anteromedial. which is dilated with an artery forceps. with the thumb and holding the soft tissues posteriorly. for example in tibial lengthening. if this is the case a drill guide and trochar should be used. The pin is directed anteriorly. while the knee is flexed and the pin is driven through the fibular head. The medial one can be used to also fix the fibula head. slightly obliquely to the wire as shown in the diagram. Alternatively a stabilizing half pin can be inserted anteriorly. This is inserted by palpating and protecting the common peroneal N. A reference wire is usually first inserted for fine wire fixation. with a direct medial to lateral wire. allowing safe pre-drilling and insertion of a 5 or 6mm half pin. Head of fibula CUT 1 2 3 CUT 2 4 5 CUT 3 6 CUT 4 CUT 5 Lateral Malleolus CUT 6 . medially and slightly distally toward the closest available ring. The half pin is inserted perpendicular to the subcutaneous border of the tibia on the medial aspect. The insertion of the wire and half pin at this level is similar to that described for Cut Two and Three.33 CHAPTER 4 Levels of the anatomical cuts of the lower extremity TIBIA and FIBULA left 1 The diagram demonstrates the wide medial and lateral access to the tibia that is available for pin insertion. The wire at this level is placed almost parallel to the frontal plane of the tibia. Tibial fixation is with a medial-oblique wire and a half pin inserted into the medial aspect of the tibia perpendicular to the medial aspect. The fine wire is inserted slightly obliquely to the transverse plane of the tibia to engage it in its widest portion. The half pin is inserted again on the medial aspect. A distal tibial reference wire is the initial fixation used.

LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY .TIBIA and FIBULA 34 INSERTION WIRES AND HALF-PINS .LEFT 2 4 1 ANTERIOR 3 CUT 1 CUT 4 ANTERIOR ANTERIOR CUT 2 ANTERIOR CUT 5 ANTERIOR ANTERIOR CUT 6 CUT 3 .

Posterior Tibial/Peroneal A. Saphenous M. making up the pes anserinus. Begin 13-15 mm distal to the articular surface. The tibia is approximately 80% can- CUT 1 cellous at this level. Alternatively a 2-3mm smooth pin can be used to transfix the proximal tibio-fibular joint. situated laterally along the posterior border of biceps femoris. Other superficial landmarks include the lateral collateral ligament attaching Head of to the fibular head.. Soleus M.V. and the saphenous N. The saphenous N. and pulled through to be flush with bone. The fibula is also becoming predominantly cancellous in composition on the posterolateral side. Gracilis A. while the knee is flexed and the pin is driven through the fibular head. The medial one can be used to also fix the fibula head. medially and slightly distally toward the closest available ring. A reference wire is usually first inserted for fine wire fixation. about a hand’s breadth medial to the medial border of the patella. Semitendinosus M. The wire is cut off flush with skin. and V. Common Peroneal M. Soleus M. except for the common peroneal N.V.N. the fibula patella tendon and the patellar tubercle inferiorly. Patellae CUT 1 M.35 CHAPTER 4 TIBIA and FIBULA left ANTERIOR Lig. Peroneal N. for example in tibial lengthening. Note: do not place the wire through the capsule. . Gastrocnemius Lateral The first cut crosses the medial and lateral tibial plateau just below the level of the knee joint. Optimum fixation is then obtained using two half pins placed anteriorly. gracilis and semitendinosus. Gastrocnemius Medial HEAD OF FIBULA N. Tibial M. run between these muscles with the inferior geniculate A. This is inserted by palpating and protecting the common peroneal N. Popliteus A. and V. The pin is directed anteriorly. if this is the case a drill guide and trochar should be used. The medial tibial surface provides attachment for the sartorius. medially. Tibialis Ant. The tibia is palpable throughout the anterior two thirds. but not posteriorly.V. Sartorius TIBIA M. The major neurovascular structures are posterior and slightly lateral. M. with the thumb and holding the soft tissues posteriorly. 2 4 1 ANTERIOR 3 Lateral Malleolus The diagram demonstrates the wide medial and lateral access to the tibia that is available for pin insertion. Extensor Hallucis Longus M. This is inserted in the transcondylar transverse plane anterior to the fibula. and the infrapatellar N emerges superficially.

Tibialis Ant. The neurovascular bundle takes a more central position in the leg here. M. At this level the whole of the anteromedial border of the tibia is palpable. Extensor Digitorum M. Common Peroneal TIBIA M. . Posteriorly the neurovascular bundle runs just posterior to the tibialis posterior muscle. Soleus M. Tibial ant.V.-post. Gastrocnemius Medial M. ANTERIOR CUT 2 Lateral Malleolus The half pin is inserted perpendicular to the subcutaneous border of the tibia on the medial aspect. N. Tibial A.TIBIA and FIBULA 36 TIBIA and FIBULA left ANTERIOR CUT 2 M. Popliteus N. which provides a useful guide to the relative crosssectional diameter of the bone. Tibialis ant. Posterior Tibial FIBULA M.V. again in the sagittal axis. The cortical component at this level is approximately 40% of the tibial diameter. A.LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY . Head of fibula with the anterior bundle lying in close proximity to the interosseous membrane in the sagittal axis. The fine wire is inserted slightly obliquely to the transverse plane of the tibia to engage it in its widest portion. Gastrocnemius Lateral This section is taken about 7-8 cm distal to the knee joint. The gastrocnemius has divided into its lateral and medial heads in the calf.

M. Posterior Tibial N. and here has its smallest diameter. The cortical component of the bone is gradually increasing. and the deep peroneal N. Gastrocnemius Medial M. At this level the fibula is more triangular in cross section. Tibial post. M. N. Gastrocnemius Lateral V. The medial border of the tibia is still located in a subcutaneous position. Tibialis Posterior FIBULA M. are centred on top of the interosseus membrane. Saphenous This section is taken about 12 cm distal to the knee joint. The anterior tibial A.37 CHAPTER 4 TIBIA and FIBULA left ANTERIOR CUT 3 M. and V.V. Superficial Peroneal M. Peroneal ant. in the sagittal plane. A. M. Head of fibula ANTERIOR CUT 3 Lateral Malleolus Tibial fixation is with a medial-oblique wire and a half pin inserted into the medial aspect of the tibia perpendicular to the medial aspect. between the tibia and fibula.V. Peroneus longus TIBIA M. Tibial ant. Flexor Hallucis A. Again the neurovascular bundles are relatively central. Tibialis post. Soleus M. Extensor Digitorum N. Tibialis Ant. .

A. tibialis posterior and flexor digitorum longus muscles. The muscular contributions remain similar with the one significant difference being the increasing mass of gastro-soleus. / N. M. Soleus This section is taken just inferior to the midpoint between the knee and ankle joints. The tibia maintains its dense cortex. . now comprising up to 80% of the cross section. Gastrocnemius FIBULA M. Tibial Ant. M.V. A. The major neurovascular bundle is very close to the geometric centre of the leg.LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY . with the tibial N. Extensor Digitorum M.V. Tibial A. Tibialis Ant. Peroneal M. The fibular now takes on a more quadrangular cross section. runs posterior and lateral to the tibia at the confluence of the soleus. Extensor Hallucis longus M. and V. The peroneal vessels remain medial in relation to the fibula. Peroneus longus TIBIA M. Tibial posterior N. Flex.TIBIA and FIBULA 38 TIBIA and FIBULA left ANTERIOR CUT 4 M. ANTERIOR CUT 4 Lateral Malleolus The insertion of the wire and half pin at this level is similar to that described for Cut Two and Three. Peroneal sup. Flexor Digitorum longus M. with a medial subcutaneous position. The posterior tibial A.V. Hallucis longus M. Peroneal Prof. The anterior bundle is Head of fibula anterior to the interosseous membrane. Tibialis post. Peroneus brevis N.

Ext. Peroneus longus M. and V. and V. with the deep peroneal N.V. The half pin is inserted again on the medial aspect. . Flexor Digitorum longus M.N. but is relatively anterior because of the increasing posterior musculature. M. with the tibial N. The fibula is not usually palpable due to the peroneal muscle mass. Hallucis long. now lying adjacent to the interosseus membrane. descending on the tibialis posterior muscle. M. run in a Head of fibula more posterior position. where the tibia remains palpable along its medial surface. ANTERIOR CUT 5 Lateral Malleolus The wire at this level is placed almost parallel to the frontal plane of the tibia. M. TIBIA M. The posterior tibial A. slightly obliquely to the wire as shown in the diagram. Tibialis Ant. Both bones at this level consist primarily of cortical bone. Peroneus brevis A. Tricipitis This section is taken at about 12 cm from the ankle joint.39 CHAPTER 4 TIBIA and FIBULA left ANTERIOR CUT 5 M. Tibial ant. Tibialis Post. The tibialis anterior and the extensor hallucis longus muscles cover these structures. The anterior tibial A. Tibial posterior FIBULA M. M. Soleus M.V. Peroneal Prof. / N. Extensor Digitorum Long. are located centrally between the soleus muscle and the deep posterior compartment. Flexor Hallucis long A.

The major tendons are also usually readily palpable in their Head of fibula subcutaneous positions. Tibial Ant. Peroneal TIBIA M. M. Ext. The fibular stabilization takes place through a lateral oblique wire directed from posterolateral to antero medial. lateral to the tibialis anterior tendon. Tricipitis (Tendo Calcaneus) The last section of the leg is taken just proximal to the ankle joint. Hallucis M.TIBIA and FIBULA 40 TIBIA and FIBULA left M. The epiphyses of both the tibia and fibula are quadrangular in cross section at this level. . with a direct medial to lateral wire. N. Digitorum long.V. M. with the tibial N. The forceps is used to displace the soft tissues and therefore protect the anterior neurovascular bundle. which is dilated with an artery forceps. ANTERIOR Lateral Malleolus CUT 6 A distal tibial reference wire is the initial fixation used. Peroneus brevis M. allowing safe pre-drilling and insertion of a 5 or 6mm half pin. M. Peroneal Prof. The posterior tibial A. Ext. and V. Tibialis post. between the flexor digitorum longus and the flexor hallucis longus tendons. A. lie between the tendons of tibialis anterior and extensor hallucis longus. Alternatively a stabilizing half pin can be inserted anteriorly. Tibialis ant. Peroneus Terzius A.V. anterior to the neurovascular bundle. M. M. 2 cm proximal to joint. Flexor Digitorum long. This should be done with care using a limited open technique through a small incision. The anterior tibial A. CUT 6 ANTERIOR A. Peroneus long.V. At this level both malleoli are well-defined. with the deep peroneal N. Flex.LEVELS OF THE ANATOMICAL CUTS OF THE LOWER EXTREMITY . and V. Additional stabilization can be achieved with a wire directed form antero lateral to posteromedial. are located in the posteromedial quadrant. Hallucis long.N. palpable landmarks. Tibial posterior FIBULA M.

A.V. up to the ASIS. and the psoas. This is particularly good for cross-pelvic fixation. FRACS (Orth) . with the deepest muscle being gluteus minimus. Posterior the crest becomes the posterior superior iliac spine. BMedSci. External Iliac which overlies the ilium and takes origin from it. Victoria. it is more difficult in larger patients. direct fluoroscopic vision is used to ensure the line taken is adequately above the hip joint.Geelong. Alternatively. Australia. small open incisions can be made and blunt retractors used to feel down the inner and outer tables of the ilium. Gluteus Maximus This is a transverse section of the pelvis at the level of the anterior superior iliac spine. followed by gluteus maximus taking a more peripheral attachment to the ilium and covering the other glutei. especially the posterior aspect. An open technique is employed at the point at which AIIS is palpated. The outer muscle group is made up of the glutei. One to three pins can be inserted in this fashion after pre-drilling. POST. Below the AIIS is the origin of the straight head of the rectus femoris. The hole is predrilled and a 5 or 6mm half pin is inserted. ILIAC SPINE Half pins can be inserted obliquely from anterolateral to posteromedial in the line of the iliac crest.V. SUPERIOR ILIAC CREST A. Richard S. with the sartorius further anterior still. Although a percutaneous method may be adopted. The tensor fascia lata takes origin from the outer aspect of the ilium in its anterior half. Care must be taken to stay at least 2 cm superior to the ASIS and to angle the pins away from this region to avoid injury to the lateral cutaneous nerve of thigh. artery and vein. . SUP. and inferiorly with the anterior inferior iliac spine which is only palpable in thin patients. These muscles separate the ilium from the major intrapelvic neu. At this point the pelvis is deep and the pin can be inserted deep into the ilium heading posterior to the ischium. From lateral to medial the femoral nerve. a straight retractor either side of the ilium can be used to guide for any pelvic obliquity as above. Gluteus Medius M. Next is gluteus medius. An additional anteroinferior half pin can be inserted at the level of the AIIS. When this is demonstrated. The ilium is a trilaminar plate with outer and inner SACRUM cortices of variable thickness. or seen under direct vision using fluoroscopy. Page. BS. descend from beneath the inguinal ligament into the femoral triangle. which overlies this. which is closely applied to the central aspect of the ilium. In this situation. Inferior to the AIIS is A. The ilium is contained between two groups of muscles.Orthopaedic Surgeon The Geelong Hospital . Tensor Fasciae Latae ANT.41 CHAPTER 5 APPENDIX PELVIS* left Transverse Section Iliac Crest M.N.V. Gluteus Minimus M. Iliopsoas M. The lateral cutaneous nerve of thigh emerges through the inguinal ligament 1cm medial to the ASIS. A four cm incision is made in line with the iliac crest and blunt dissection is used to expose the AIIS where the straight head of rectus femoris inserts. as it descends from its origin on the lateral masses of the lumbar spine. Femoral rovascular structures and viscera. the vessels entering the femoral canal within their sheath. MB. The ASIS is a superficial structure in most patients in continuity with the iliac crest superiorly. Internal Iliac the roof of the acetabulum and the hip joint. * Chapter contributed by: Dr. An anterior to posterior wire can then be inserted as a guide while a plain XR is taken. providing excellent fixation. This helps to give an appreciation of the orientation of the ilium. spaced for maximal purchase. containing an inner layer of cancellous bone. which is approximately 30° from the vertical. which is the point the inguinal ligament attaches. The musculature of the anterior abdominal wall takes origin from the superior aspect of the ilium. Gluteal Vessels M. Care must be taken with retraction to avoid excessive traction on the lateral femoral cutaneous nerve of thigh. The inner group comprises iliacus.

Iliopsoas A. Finally a 5 or 6 mm pin is inserted in a line clear of the hip joint through a pre-drilled hole. An additional lateral half pin can be inserted into the ilium. The surface point for insertion is the midpoint in a line between the ASIS and the tip of the greater trochanter. Gluteus Medius M. The internal and external iliac vessels can be seen on the inner aspect of iliacus where the femoral N. or by inserting a wire at the entry point perpendicular to the lateral mass of the buttock. Coronal Section ILIAC CREST SACRUM M. They leave the pelvis via the sciatic foramen. Here the bony landmarks are again the ASIS. gluteus medius and the tensor fascia lata. and A. On the inner table lies the iliacus muscle. and more distally the greater trochanter. and on the outer table lie the glutei. Gluteus Maximus M. the AIIS in thinner patients. The surface marking for the superior bundle is 5cm proximal to the tip of the greater trochanter. The superior gluteal N. An open technique is used for insertion. a small incision is made in the skin and a straight artery forceps used to dilate the opening in line with the glutei down to the ilium. with the thick portion of ilium above the acetabular roof leading to the quadrate plate. supplies the gluteus maximus muscle (L5-S2). The pelvis is wide at this point and good fixation is achieved. come to run between iliacus and psoas.APPENDIX 42 PELVIS left This is a coronal section taken through the hemi-pelvis at the centre of the hip joint. while the inferior gluteal N. The neurovascular structures within the glutei are the superior and inferior gluteal neurovascular bundles respectively. An XR image can then by taken to confirm the entry point and ensure the line of the pin will be clear of the hip joint. The acetabulum is shown in cross-section. above the hip joint. External Iliac M. Gluteus Minimus FEMUR The superior iliac half pin is inserted as described above. the superior above and the inferior below the piriformis muscle. At this point guidance is either by direct vision under fluoroscopic control. (L4-S1) supplies the gluteus minimus. The point of the concavity where the acetabular roof meets the iliac crest is then felt. The bone here has both thicker cortices and a wider cancellous component. gluteus medius and gluteus maximus. From here they travel in the plane between the gluteus minimus and medius muscles.V. . the gluteus minimus. which from medial to lateral are.

Dorsal Metacarpal PROXIMAL PHALANX OF FIRST DIGIT A. one from the fourth to the second metacarpal.N.N. Interossei CUT 1 DISTAL SECTION DORSAL VIEW Adductor Pollicis METACARPAL SHAFTS II-V M.V.43 CHAPTER 5 METACARPAL left M. .V. these bones are metaphyseal and quadrangular. Flexor Digiti Quinti Brevis Opponens Digiti Quinti M. Palmar Median Common Digital A.N. For delta fixation a couple of 2-3 mm Steinmann pins are inserted dorsally in every metacarpal of the hand. Those pins transfix both cortices of the metacarpal. one wire can transfix the first metacarpal directed from anterior to posterior. one from the fifth to the third. With the exception of the first. Palmar Ulnar Common Digital A. DORSAL VIEW CUT 1 At this level it is possible to insert one wire from the fifth to the second metacarpal. Palmar Median Digital The cut is located at the base of the first metacarpal. Abductor Digiti Quinti A. angulated about 30° to 50°. The metacarpal 2 through 5 are located dorsally with only the extensor tendons and superficial vein posterior to them. avoiding the extensor tendons. For the first metacarpal the pins are inserted laterally. The flexor tendons and neurovascular structures are located centrally between the tenar and hypotenar muscle masses.V.

Flexor Digiti Quinti Brevis M.N.II-V A. Opponens Digiti Quinti M. The four medial metacarpals are diaphyseal and cortical. in lateral position for the first metacarpal. Opponens Pollicis M. The flexor and extensor tendons of the medial four rays lie volare and dorsal respectively. Adductor Pollicis M. Ulnar N. Flexor Pollicis Brevis M. angulated about 20°-30°.5. Palmar Ulnar A. DORSAL VIEW CUT 2 At this level the possibility of wire insertion are: one from the fifth to the third metacarpal and a second from the third to the second metacarpal.V.FIRST METACARPAL M. in dorsal position for the metacarpal 2. it is possible to apply a delta fixation to every metacarpal: we use a 2. . 3.N. Interossei CUT 2 METACARPAL BASES . To avoid the transfixation of palmar soft tissues. Branches of Prof.V. Prof.APPENDIX 44 METACARPAL left PROXIMAL SECTION DORSAL VIEW M. Abductor Digiti Quinti A. 4. Flexor Digitorum Profundus. Abductor Pollicis Brevis The cut is located at the base of the proximal phalanx of the thumb.V. Palmar Arch Dorsal Branch of Radial A M. angulated between 30° to 90°. 3 mm Steinmann pins. For the first metacarpal it is possible to insert one or two wires from anterior to posterior. while the first is metaphyseal and quadrangular. The major neurovascular structures are volar between the metacarpals and the palmar aponeurosis. Median and Common Digital Branches T. Flexor Digitorum Sublimis. Lumbricals I . 5.

Flexor Hallucis T. tangent to the medial malleolus to avoid the neuro vascular bundle. inf. . Wires d: For talus fixation in case of ankle fusion on sub talar join fusion. Peroneus longus CUT 0 Posterior tibial Vein.M. Flexor Hallucis longus Posterior Talofibular Ligament T.45 CHAPTER 5 ANKLE JOINT left FRONTAL VIEW TIBIA Interosseous Membrane Ant. from distal to proximal: smooth wire for fixation of medial malleolar fracture. it is enough just to push on the wire. Wire b: From postero lateral to antero medial from distal to proximal for fixation of the lateral melleolus to the tibia in fracture or special case of lengthening: this wire is tensioned with post at the same ring or in different rings. Artery and Tibial Nerve CALCANEUS c c d b a Wire a: From lateral to medial. Wire c: This is half wire on half pin diameter 2 to 5 mm for fibular fixation in the need to move down the fibula or for differential lengthening of the fibula. some time olive wire. Tibialis posterior M. Tibio-fibular Lig. to compress the fragment. Peroneus Brevis T.M.M. the AP wire into the fibula has to be avoided not to damage the soft tissues. the direction is from postero lateral to antero medial and from postero medial to antero lateral. It is not necessary to cross all the tibia.M. TIBIAL MALLEOLUS FIBULAR MALLEOLUS TALUS Deltoid Medial Ligament T. In this way there is not risk to damage the lateral soft tissues and the pressure to the bone is not so strong to allow the olive to penetrate into the soft bone as the malleolar cortex is very soft.

Ext.APPENDIX 46 ANKLE JOINT left ANTERIOR CUT 0 T. T.M. Plantaris T. Flexor Hallucis longus T. N. Peroneal prof. Tibial ant.M. Tibialis A.M. Ext. Tibialis posterior T. Tricipitis (Tendon Calcaneus) d c a b c d d .M.M. Peroneal TALUS TIBIAL MALLEOLUS FIBULA T.M.M. A.M. T. Tibialis ant.V. Peroneus longus T.M. Hallucis T. Peroneus brevis T. Flexor allucis N.V.M. Tibial posterior T. Digitorum long.M.

47 CHAPTER 5 FOOT left Os calcaneum Medial Malleolus Lateral Malleolus section large tarsal bones Talus CUT 0 Head of Talus Tubercolum 5º metatarsal section small tarsal bones Navicular bone Cuboid bone 1st medial cuneiform bone 2nd Middle cuneiform bone 3rd lateral cuneiform bone CUT 1 Iº Metatarsal post. middle. tubercolus CUT 2 section bones of anterior half of the foot 1 2 3 4 5 Metatarsal bones Proximal (1st) phalanges Middle (2nd) phalanges Distal (3rd) phalanges Dorsum of the foot vessels. into three sections: anterior. nerves and tendons The bones are divisible. and posterior Medial calcaneal arteries The artery of the foot dorsal Arcuate artery Dorsal artery of the foot Lateral tarsal artery Common dorsal digital arteries Common dorsal digital arteries Proper dorsal digital arteries . at the transverse tarsal and tarso-metatarsal joints.

the medial and lateral calcaneal processes leading to the calcaneal body on either side. A. and two half pins are then inserted from the posterior aspect of the calcaneus.V. This combination achieves optimal hindfoot stability.V.APPENDIX 48 FOOT left DORSAL VIEW Hindfoot POSTERIOR VIEW TALUS N. However. and the plantar vessels and N. behind the medial malleolus. The calcaneus is predominantly a cancellous structure. V. Peroneal prof. to about 5cm from the anterior process of the calcaneus. because of the bone structure these do not give fixation that is as good as the wire and half pin combination. Here both malleoli are readily palpable. with the posterior tibial A. This is placed onto a half ring. pass inferiorly adjacent to the tendon of flexor hallucis longus. The view is from above looking down on the talus and calcaneus. which is closest to bone. They are placed posterior to anterior at about 60°-90° to each other. running between this and the flexor hallucis longus tendon. and on the lateral surface the calcaneoDORSAL VIEW cuboid joint distally and anteriorly. Alternatively crossed wires can be inserted. centred in the posterior aspect of the calcaneus. Tibial A. Tibial Posterior CALCANEUS CALCANEUS The first section is taken transversely at the level of the distal tibia. Posterior to the medial malleolus runs the tibialis posterior tendon. POSTERIOR VIEW An oblique lateral to medial wire. as is the posterior tibial A. provides the initial hindfoot fixation. On the medial aspect of the hindfoot the sustentaculum tali is palpable anteromedial to the distal tip of the medial malleolus. midway along the calcaneal process. and the posterior tibial N. The other bony landmarks palpable at this level are the calcaneal tuberosity for the insertion of the tendo-Achilles. particularly in older patients. with a thin cortical shell. . The tendon of the flexor digitorum longus is the next posterior structure. Here the medial subtalar facet is positioned above. positioned at the height of the inferior aspect of the calcaneal tuberosity. Dorsalis Pedis CUT 0 N.

creating a stable bony arch with the highest point being around the third metatarsal. especially in the smaller foot. The first metatarsal in particular has a considerable cancellous centre with thick cortices. . This fixation can be supplemented for stability using 2-3mm Steinmann pins. fourth and third metatarsals as shown.49 CHAPTER 5 FOOT left CUT 1 Midfoot (Metatarsal Bases) M. Extensor Digitorum Brevis CUT 2 Forefoot T. Alternatively. The second wire enters from the lateral side. Adductor Hallucis A. Medial/Lateral Plantar M. about 1cm distal to the tarsometatarsal joints. The extensor digitorum tendon to the little toe. Peroneus Longus M. and deep peroneal N. Abductor Hallucis M. The tendon of extensor hallucis longus lies over the first metatarsal. the extensor digitorum longus with the brevis tendons over the third and fourth. over the second. The first from the medial side. The bases of the bones fit together in cross section like keystones in an archway. Extensor Digitorum Longus METATARSAL SHAFT . 3-5 mm ∅ 3-4 mm ∅ Fixation at this level is initially achieved by crossed wires. At this level the metatarsals have reasonably thick cortices with a medullary core. Extensor Hallucis Longus/Brevis M. obliquely and dorsally through the bases of first. Medial/Lateral Plantar This section is taken through the metatarsal bases.N. Flexor Digitorum Brevis A. second and third metatarsals. If a first metatarsal pin is used care must be taken to spread the soft tissues with an artery to protect the dorsal neurovascular structures. the navicular or cuneiforms can be used as insertion points medially. extensor tendons and laterally by extensor digitorum brevis.V. Flexor Hallucis Brevis M. The dorsal surface is quite superficial.II-V Styloid Process (V) M. and the cuboid can be used laterally as insertion points. base and shaft of the fifth metatarsal. Note: it is possible to use 1st to 5th metatarsal wire. Flexor Hallucis Brevis M. Abductor Digiti Quinti M. Abductor Hallucis M. The extensor retinaculum ends distally at the level of the tarso-metatarsal joints. but this one fixes the fifth. Abductor Digiti Quinti M. again obliquely and dorsally. the dorsalis pedis A. covered only by skin and fascia. with that of abductor digiti minimi lies over the dorsum.N. These can be inserted into the centre of the metatarsal base from the dorsal aspect of the foot.V. or in the case of the first metatarsal base using a threaded half pin.

These wires/pins cross at an angle of 30-40 degrees.APPENDIX 50 FOOT left clinical examples In the transosseous osteosynthesis the extended device to foot is used to increase the stability in the ankle or in the distal tibial epiphysis pathologies. The frame is fixed posteriorly by a transverse wire and a 5 mm half pin. These wires pass transversely through the tarsal bones and the bases of the metatarsals. . The hybrid system suggests the use of 1 or 2 half-pins in the calcaneum according to the following method: the foot construct consists of a half ring posteriorly with threaded plates extending anteriorly from each end. to improve the stability one half pin is inserted perpendicular to the first metatarsus. The examples can be numerous according to the different pathologies. Another half ring is used to connect the threaded plates anteriorly over the dorsum of the foot. Two or three wires are used to fix the midfoot and forefoot.

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